Family Eye Care of O Fallon, P.C. 852 Cambridge Blvd, #200 O Fallon, IL 62269 (618) 628-2903 www.ofallonfec.com Welcome to Family Eye Care of O Fallon! We look forward to providing you with personalized, professional service. To help your visit go more efficiently, please arrive 15 minutes early for your first appointment, and please bring the following items with you: o Completed Patient Health History and Patient Registration forms (Below); o Completed List of current medications and supplements See below, or a more comprehensive form may be found here. o Current Medical Insurance card and any Optical Insurance card you may have. It is important to inform us at the time of your visit of any Optical Insurance you would like to use. Optical Insurance cannot be directly applied after the visit or after glasses/contacts have been ordered. o Current glasses and/or contacts, or the prescription for either. Empty contact lens boxes are also great to bring with you. And please note that a parent or legal guardian must accompany all minors under the age of 18 for the first visit. If you have any questions before then, please feel free to call us. If you cannot make your appointment for any reason, please let us know as soon as possible. All of us at Family Eye Care of O Fallon are excited to see you for your visit! Thank you for trusting us with the health of your eyes, The Doctors and Staff of Family Eye Care Page 1 of 5
Welcome to Family Eye Care of O Fallon Patient Registration Form Status q Existing Patient q New Patient Salutation q Mr. q Mrs. q Ms. q Miss q Dr. q Other Full Name (First, Middle, Last) Gender q Male q Female Today s Date Marital Status q Married q Single Nickname q Other PATIENT INFORMATION Home Address City State Zip Date of Birth Social Security Number Name of Parent or Guardian (If applicable) Preferred Language Race q American Indian or Alaskan Native q Asian q Black or African American q Native Hawaiian or other Pacific Islander q White q Other q Unknown Ethnicity q Non-Hispanic or Latino q Hispanic or Latino Dominant Eye q Right q Left q Unknown Employed Occupation / Student Grade Level Employer / School Position / Major Name of Primary Care Physician (PCP) PCP City PCP State PCP Phone COMMUNICATION Home Phone Work Phone How would you like for us to communicate with you? Home Phone Work Phone Email Mail Appointment confirmation q q q q Recall for future appointment q q Order status q q q q Educational material q Email REFERRAL How did you hear about us? q N/A - I am an Existing Patient q Doctor q Family Member q Friend q Internet q Advertisement Name of referring Doctor Doctor work phone Doctor work fax Name of referring Family or Friend May we contact them to say Thank you? q Yes q No EMERGENCY Who should we contact in case of an emergency? Name Relationship Home Phone Name Relationship Home Phone Continue other side à Page 2 of 5
Do you have insurance? q Yes I have insurance coverage. q No I do not have insurance coverage. Further, I understand that I am responsible for payment and services rendered to myself or my dependents at the time of service. Vision Insurance Company Policy Holder Name INSURANCE INFORMATION ASSIGNMENT OF BENEFITS Policy Holder Relationship to Patient Policy Holder DOB Policy Holder SSN Policy Holder s Employer Medical Insurance Company Policy Holder Name Policy Holder Relationship to Patient Policy Holder DOB Policy Holder SSN Policy Holder s Employer Member ID Group # Plan Name Co-Pay Are there additional family members covered by this insurance? q Yes q No Name Relationship to Policy Holder DOB Coverage Insurance Authorization and Assignment: I request that payment of authorized private insurance company benefits, Medicare and Medicaid services or other applicable benefits be paid on my behalf to Dr. Vivian Kloke of Family Eye Care of O Fallon, P.C. for any furnished services. I authorize Family Eye Care of O Fallon, P.C. to release any medical or other information about me to any private insurance company, Medicare and Medicaid or other company and its agents which might provide coverage to me. All Services are the Responsibility of the Patient: I understand that insurance benefits must be determined prior to my exam. If I become aware of insurance coverage after services have been rendered, I agree that I am personally responsible for submitting the claim to my insurance company for reimbursement. I understand that when my insurance company requires a referral from my primary-care physician, and I do not furnish the correct referral at the time of service, I will be responsible for payment if my insurance company refuses my claim. I also understand and acknowledge that I am financially responsible for non-covered services and any unpaid insurance balance over 45 days past due. Payments, Co-pays and Deductibles are Due at Time of Service: I understand that not all services and materials may be covered by my insurance or may exceed benefits or coverage. I agree to pay all payments, co-pays and deductibles at the time of service for all services and materials. Returned Checks: I understand there is a $25.00 fee for any check returned by the bank. This fee will be added to the unpaid balance and both must be paid by cash or credit card. Collections: I understand that if I fail to pay amounts owed, Family Eye Care of O Fallon, P.C. has the right to secure an outside collection agency and/or attorney to collect the unpaid debt and to report the unpaid debt to a credit reporting agency. I further understand that I will be responsible for any additional charges or fees necessitated by securing the collection agency or attorney, including reasonable attorney s fees. With my signature, I confirm all of the above Patient Registration Form information is true and correct, and that I have read, understood and agree to the Assignment of Benefits section. Please print name of Patient, Parent, Guardian or Personal Representative Signature of Patient, Parent, Guardian or Personal Representative Relationship to Patient Date Page 3 of 5
Family Eye Care of O Fallon Patient Health History Name Do you take medications for, or have any of the following conditions? Constitution q Cancer q Chronic Fatigue q Developmental Disorder Ear Nose and Throat q Dry mouth q Hearing Loss q Laryngitis q Sinusitis Neuro q Cerebral Palsy q Epilepsy q Migraine q Multiple Sclerosis q Stroke/CV q Tumor Date Psychiatric q Anxiety Disorder q Attention Deficit q Bipolar q Depression HEALTH HISTORY Cardiovascular q Congestive Heart Failure q Heart Disease q Hypertension q Vascular Disease q Stroke/CVA Respiratory q Asthma q Chronic Obstruction q Sleep Apnea q Emphysema Gastrointestinal q Acid Reflux q Celiac disorder q Colitis q Crohn s Disease q Ulcer Genitourinary q Herpes q Kidney Disease q Nursing q Prostate qdisease/cancer? q STD: Musculoskeletal q Ankylosing Spondylitis q Arthritis q Muscular dystrophy q Osteoarthritis q Osteoporosis Allergy/immune q Lupus q Sjogren s Syndrome q Rheumatoid Arthritis Integumentary (skin) q Eczema q Herpes simplex/cold sores q Herpes zoster/shingles q Psoriasis q Rosacea Additional Comments Endocrine q Hormonal dysfunctions q Thyroid Dysfunction q Type I Diabetes q Type II Diabetes Hem/Lymph q Ulcer q Anemia q High Cholesterol Medication Name Dosage Prescribing Doctor Reason Start date MEDICATIONS Continue other side à Page 4 of 5
ALLERGIES Medication Allergies q No known Non-Medication Allergies (Animal, Plant, Food, Etc.) q No known OCULAR & SOCIAL HISTORY Do you currently have, or had, any of the following? q Amblyopia q Glaucoma Suspect q Cataract q Inflammatory Disorder q Dry eye q Injury q Glaucoma q Keratoconus q LASIK / PRK q Macular Degeneration q Nystagmus q Patching q Retinal Degeneration q Retinal Detachment q Retinal Hole q Strabismus q Surgery Smoking Status q Current everyday smoker (Smoked at least 100 cigarettes during lifetime and still smokes everyday) q Current some day smoker (Smoked at least 100 cigarettes during lifetime and still smokes periodically yet consistently) q Former smoker (Smoked at least 100 cigarettes during lifetime but does not currently smoke) q Never smoker (Not smoked 100 or more cigarettes during lifetime) FAMILY HISTORY Has anyone in your family had one or more of the following conditions? q Cancer q Diabetes q Hypertension q Thyroid q Amblyopia (Lazy Eye) q Cataract q Dry Eye q Glaucoma q Glaucoma Suspect q Macular Degeneration q Nystagmus q Severe Hyperopia q Severe Myopia q Strabismus (Eye Turn) q Retinal Detachment VISION WEAR Eyeglass q Never Worn q Distance Only q Near Only q Lined Bi/Trifocal q Progressive (No-Line) Contact Lens q Never Worn q Soft Lenses q Gas Permeable Lenses q Hard Lenses Eye Prescription (If known): Brand: q Right q Left Average Daily Wearing Time: Average Replacement Period: Continuous Wear Period: Solution Used: Drops Used: Additional comments: Is there anything we may do to make your visit to Family Eye Care of O Fallon more pleasurable? VISIT With my signature, I confirm all of the above Patient Health History information is true and correct to the best of my knowledge. Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient Signature of Patient, Parent, Guardian or Personal Representative Page 5 of 5 Date